TY - JOUR
T1 - Effect of using the HEART score in patients with chest pain in the emergency department
T2 - A Stepped-wedge, cluster randomized trial
AU - Poldervaart, Judith M.
AU - Reitsma, Johannes B.
AU - Backus, Barbra E.
AU - Koffijberg, Hendrik
AU - Veldkamp, Rolf F.
AU - Ten Haaf, Monique E.
AU - Appelman, Yolande
AU - Mannaerts, Herman F.J.
AU - Van Dantzig, Jan Melle
AU - Van Den Heuvel, Madelon
AU - El Farissi, Mohamed
AU - Rensing, Bernard J.W.M.
AU - Ernst, Nicolette M.S.K.J.
AU - Dekker, Ineke M.C.
AU - Den Hartog, Frank R.
AU - Oosterhof, Thomas
AU - Lagerweij, Ghizelda R.
AU - Buijs, Eugene M.
AU - Van Hessen, Maarten W.J.
AU - Landman, Marcel A.J.
AU - Van Kimmenade, Roland R.J.
AU - Cozijnsen, Luc
AU - Bucx, Jeroen J.J.
AU - Van Ofwegen-Hanekamp, Clara E.E.
AU - Cramer, Maarten Jan
AU - Six, A. Jacob
AU - Doevendans, Pieter A.
AU - Hoes, Arno W.
PY - 2017/5/16
Y1 - 2017/5/16
N2 - Background: The HEART (History, Electrocardiogram, Age, Risk factors, and initial Troponin) score is an easy-to-apply instrument to stratify patients with chest pain according to their short-term risk for major adverse cardiac events (MACEs), but its effect on daily practice is unknown. Objective: To measure the effect of use of the HEART score on patient outcomes and use of health care resources. Design: Stepped-wedge, cluster randomized trial. (Clinical Trials.gov: NCT01756846) Setting: Emergency departments in 9 Dutch hospitals. Patients: Unselected patients with chest pain presenting at emergency departments in 2013 and 2014. Intervention: All hospitals started with usual care. Every 6 weeks, 1 hospital was randomly assigned to switch to "HEART care," during which physicians calculated the HEART score to guide patient management. Measurements: For safety, a noninferiority margin of a 3.0% absolute increase in MACEs within 6 weeks was set. Other outcomes included use of health care resources, quality of life, and cost-effectiveness. Results: A total of 3648 patients were included (1827 receiving usual care and 1821 receiving HEART care). Six-week incidence of MACEs during HEART care was 1.3% lower than during usual care (upper limit of the 1-sided 95% CI, 2.1% [within the noninferiority margin of 3.0%]). In low-risk patients, incidence of MACEs was 2.0% (95% CI, 1.2% to 3.3%). No statistically significant differences in early discharge, readmissions, recurrent emergency department visits, outpatient visits, or visits to general practitioners were observed. Limitation: Physicians were hesitant to refrain from admission and diagnostic tests in patients classified as low risk by the HEART score. Conclusion: Using the HEART score during initial assessment of patients with chest pain is safe, but the effect on health care resources is limited, possibly due to nonadherence to management recommendations.
AB - Background: The HEART (History, Electrocardiogram, Age, Risk factors, and initial Troponin) score is an easy-to-apply instrument to stratify patients with chest pain according to their short-term risk for major adverse cardiac events (MACEs), but its effect on daily practice is unknown. Objective: To measure the effect of use of the HEART score on patient outcomes and use of health care resources. Design: Stepped-wedge, cluster randomized trial. (Clinical Trials.gov: NCT01756846) Setting: Emergency departments in 9 Dutch hospitals. Patients: Unselected patients with chest pain presenting at emergency departments in 2013 and 2014. Intervention: All hospitals started with usual care. Every 6 weeks, 1 hospital was randomly assigned to switch to "HEART care," during which physicians calculated the HEART score to guide patient management. Measurements: For safety, a noninferiority margin of a 3.0% absolute increase in MACEs within 6 weeks was set. Other outcomes included use of health care resources, quality of life, and cost-effectiveness. Results: A total of 3648 patients were included (1827 receiving usual care and 1821 receiving HEART care). Six-week incidence of MACEs during HEART care was 1.3% lower than during usual care (upper limit of the 1-sided 95% CI, 2.1% [within the noninferiority margin of 3.0%]). In low-risk patients, incidence of MACEs was 2.0% (95% CI, 1.2% to 3.3%). No statistically significant differences in early discharge, readmissions, recurrent emergency department visits, outpatient visits, or visits to general practitioners were observed. Limitation: Physicians were hesitant to refrain from admission and diagnostic tests in patients classified as low risk by the HEART score. Conclusion: Using the HEART score during initial assessment of patients with chest pain is safe, but the effect on health care resources is limited, possibly due to nonadherence to management recommendations.
UR - http://www.scopus.com/inward/record.url?scp=85021627303&partnerID=8YFLogxK
U2 - https://doi.org/10.7326/M16-1600
DO - https://doi.org/10.7326/M16-1600
M3 - Article
C2 - 28437795
SN - 0003-4819
VL - 166
SP - 689
EP - 697
JO - Annals of Internal Medicine
JF - Annals of Internal Medicine
IS - 10
ER -